Hemorrhage in Trauma

Basic rules of suturing

During surgical closure of traumatic defects, it is essential to strictly adhere to several fundamental principles, regardless of the chosen suture type.

First, the wound must be completely free of any dead spaces or pockets. Tissue edges require maximum adaptation and precise alignment with each other. Second, the suture material used must be removable. Leaving ligatures deep in the tissues, even if it is absorbable catgut, is unacceptable. Any foreign body becomes a powerful trigger for a purulent-inflammatory process. Third, when placing secondary sutures, it is vital to carefully preserve the existing granulation tissue. It performs a crucial barrier function, reliably protecting the deep layers from further spread of infection, and significantly simplifies the surgical technique itself. Wounds closed in this manner that avoid suppuration heal with the formation of a linear scar (by primary intention), although the mechanism differs as the process proceeds through the maturation of granulations.

Pathogenesis of infectious complications

If necrotic tissue remains deep within the wound, it becomes an ideal breeding ground for pathogens. Microorganisms begin to actively release aggressive exotoxins, among which myotoxins, hemolysins, and neurotoxins are distinguished.

The action of these toxic substances leads to a cascade of pathological reactions:

• Progressive necrosis of surrounding structures develops.
• A sharp, rapidly escalating edema occurs. Because the edema develops within closed fascial compartments, it critically exacerbates tissue ischemia.
• Massive blood hemolysis occurs in combination with the breakdown of muscle fibers. This leads to the imbibition (soaking) of the subcutaneous tissue and skin, causing characteristic blue and bronze spots to appear on the patient's body.
• Gas production begins in the tissues (especially characteristic of Cl. perfringens).

The absorption of hemolysis products and exotoxins into the systemic circulation causes severe general intoxication of the body. Additionally, the situation is frequently complicated by the onset of putrefactive decay due to secondary infection.

Clinical presentation

Symptoms develop rapidly and affect both the general condition and local changes.

Early general signs: The patient's neuropsychiatric status changes dramatically: inappropriate behavior is observed, which can manifest as severe anxiety and agitation, or complete lethargy (adynamia). Marked tachycardia (rapid pulse) and fever are noted. The patient complains of severe bursting pain directly in the wound, tenderness along the vascular bundle, and a subjective feeling of the bandage being "too tight".

Local changes upon examination:

• The nature of the wound discharge changes.
• The wound edges become edematous, and the muscles literally bulge outward.
• Blisters form on the skin.
• The ligature sign appears: the bandage leaves deep indentation marks, and the placed sutures "cut into" the tissues.
• The edema itself has a specific density: after finger pressure, no pits or indentations remain on the skin. At the same time, clearly defined depressions are visible around the hair roots on the edematous tissue. The edema rapidly spreads to the entire segment or even the entire limb.

Palpation reveals the crepitus sign (a crunching sensation due to gas in the tissues), and percussion (tapping with an instrument or shaving hair) produces a metallic sound — the spatula sign. In extremely rare cases, a mixed form combining manifestations of cellulitis and necrotic myositis may occur.

Class and exam questions

What else to study on this topic

• Mechanisms of healing by primary intention through granulation maturation
• Properties and types of exotoxins (myotoxin, hemolysin, neurotoxin)
• Pathogenesis of ischemia development within fascial compartments during increasing edema
• Differential diagnosis of the mixed form: combination of cellulitis and necrotic myositis
• Assessment of the patient's neuropsychiatric status during acute intoxication

Other topics in "CHAPTER 10. GENERAL ISSUES IN TRAUMATOLOGY"

Prepared by WhiteCoat Pro faculty in accordance with the medical school curriculum. For educational purposes only.